The role of benzydamine in prevention and treatment of chemoradiotherapy-induced mucositis

A longitudinal assessment of major mouthwashes used in alleviating pain and xerostomia among advanced nasopharyngeal carcinoma patients receiving chemoradiotherapy

OBJECTIVE

This longitudinal study aimed to evaluate the overall efficacy of mouthwashes in oral mucositis pain and mucositis xerostomia in advanced nasopharyngeal carcinoma (NPC) patients undergoing concurrent chemoradiotherapy (CCRT) at different phases throughout treatment.

METHODS

A longitudinal study enrolled 79 advanced NPC subjects receiving CCRT. The subjects were interviewed prospectively three times over 7 weeks for pain and xerostomia scores based on the various types of mouthwash used. The median pain score difference and median xerostomia score difference were utilised to determine mouthwash superiority.

RESULTS

Participants completed three interviews, during which 480 instances of mouthwash use were observed throughout different phases of the treatment period. The results showed that the median pain scores between mouthwashes differed significantly, H-Stat(3) = 30.0, 25.7 and 26.0, respectively, with p < 0.001 for all three interviews. The pain score reductions of lidocaine mouthwash (median = 2, interquartile range (IQR) = 3, 2 and 2.75 over the three interviews, respectively) were significantly higher than those of benzydamine and sodium bicarbonate mouthwashes. There were no significant differences between the studied mouthwashes in their xerostomia score reductions.

CONCLUSIONS

Lidocaine mouthwash was superior in managing oral mucositis pain at all phases throughout the entire chemoradiotherapy treatment for advanced NPC patients. There was insufficient evidence to determine the preferred mouthwash for treating oral mucositis xerostomia.

Dentist Involvement in the Treatment of Radiation-Induced Oral Mucositis-A Pilot Cross-Sectional Study

Objectives: Oral mucositis (OM) occurs in more than 95% of patients irradiated in the head and neck area. This paper aims to determine the occurrence and characteristics of OM in patients with head and neck cancer (HNC), as well as the involvement of dentists/oral medicine specialists in treating such patients. Methods: This study was conducted at the Department of Otorhinolaryngology and Department of Oral Medicine, University Hospital Center Zagreb, from April to August 2022, on patients irradiated in the head and neck area. A unique OM questionnaire was created on the incidence, characteristics, oral care, and involvement of dentists in the overall care. Results: Thirty patients filled out the questionnaire. Of the 22 patients who had developed OM, 14 had grade-three OM. Ten patients were treated for OM in line with the instructions of an oral medicine specialist, eight based on the instructions of a specialist responsible for monitoring of the underlying disease, and four were not treated at all. Sixteen patients had not been referred to a dentist before the start of RT. Conclusions: These results showed insufficient care and treatment of OM, as well as insufficient involvement of dentists in the oncology team.

Efficacy and safety of NAHAO® hydrogel in amelioration of chemoradiotherapy-induced oral mucositis: An preliminary clinical study (ChiCTR2200064766)

OBJECTIVE

To evaluate the efficacy of NAHAO® oral mucosal antibacterial care solution (NAHAO® spray) on attenuating oral mucositis (OM) symptoms and related mechanisms investigation.

MATERIAL AND METHODS

Experimental OM models were established by acetic acid and 5-fluorouracil combined with mechanical trauma. We investigated spontaneous pain of conscious OM rats after using NAHAO®. The expression of NF-κB in affected trigeminal ganglion was measured by western blot. In clinical study, 60 patients who developed post-treatment OM of grade 2 or above or persistent mucosal pain with a score equal to or greater than 4 points were selected. All patients were required to receive NAHAO® spray 8 times a day and were examined for OM degrees and oral mucosal pain scores before and after application.

RESULTS

Experimental data from experimental model suggested that clinical efficacy of NAHAO® spray was involved in inflammation inhibition via NF-κB pathway. The results of clinical study showed that NAHAO® spray improved the symptoms of OM, there is statistically significant difference in oral mucosal pain scores after treated with NAHAO, and the dietary restrictions were also improved.

CONCLUSION

NAHAO® spray alleviates pain and improves the diet situation in OM patients, which is partly mediated through the inhibition of NF-κB pathway.

Novel Sprayable Thermosensitive Benzydamine Hydrogels for Topical Application: Development, Characterization, and In Vitro Biological Activities

Benzydamine hydrochloride (BZD) having analgesic, anesthetic, and anti-inflammatory effects is used orally or topically in the treatment of disorders such as joint inflammation and muscle pain. Within the scope of this study, sprayable thermosensitive BZD hydrogels were developed using thermoresponsive poloxamers to avoid systemic side effects and to provide better compliance for topical administration. Also, hydroxypropyl methyl cellulose (HPMC) was employed to improve the mechanical strength and bioadhesive properties of the hydrogel. The addition of BZD generally decreased the viscosity of the formulations (p < 0.05), while increasing the gelation temperature (p < 0.05). The formulations that did not have any clogs or leaks in the nozzle of the bottle during the spraying process were considered lead formulations. To spray the formulations easily, it was found that the viscosity at RT should be less than 200 mPa·s, and their gelation temperature should be between 26 and 34°C. Increasing HPMC and poloxamer improved bioadhesion. The amount of HPMC and poloxamers did not cause a significant change in the release characteristics of the formulations (p > 0.05); the release profiles of BZD from the formulations were similar according to model-independent kinetic (f2 > 50). HPMC and poloxamers had important roles in the accumulation of BZD in the skin. In vitro biological activity studies demonstrated that the formulations presented their anti-inflammatory activity with TNF-α inhibition but did not have any effect on the inhibition of COX enzymes as expected. As a result, thermosensitive hydrogels containing BZD might be an appropriate alternative, providing an advantage in terms of easier application compared to conventional gels.

Mitochondrial Metabolism: A New Dimension of Personalized Oncology

Energy is needed by cancer cells to stay alive and communicate with their surroundings. The primary organelles for cellular metabolism and energy synthesis are mitochondria. Researchers recently proved that cancer cells can steal immune cells' mitochondria using nanoscale tubes. This finding demonstrates the dependence of cancer cells on normal cells for their living and function. It also denotes the importance of mitochondria in cancer cells' biology. Emerging evidence has demonstrated how mitochondria are essential for cancer cells to survive in the harsh tumor microenvironments, evade the immune system, obtain more aggressive features, and resist treatments. For instance, functional mitochondria can improve cancer resistance against radiotherapy by scavenging the released reactive oxygen species. Therefore, targeting mitochondria can potentially enhance oncological outcomes, according to this notion. The tumors' responses to anticancer treatments vary, ranging from a complete response to even cancer progression during treatment. Therefore, personalized cancer treatment is of crucial importance. So far, personalized cancer treatment has been based on genomic analysis. Evidence shows that tumors with high mitochondrial content are more resistant to treatment. This paper illustrates how mitochondrial metabolism can participate in cancer resistance to chemotherapy, immunotherapy, and radiotherapy. Pretreatment evaluation of mitochondrial metabolism can provide additional information to genomic analysis and can help to improve personalized oncological treatments. This article outlines the importance of mitochondrial metabolism in cancer biology and personalized treatments.

Sumac-rose water mouthwash versus benzydamine to prevent radiation-induced oral mucositis in head and neck cancers: a phase II randomized trial

BACKGROUND

Radiation-induced oral mucositis (OM) largely impairs the quality of life (QoL) of patients with head and neck cancer (HNC). Few choices with limited efficacy are available to prevent this adverse effect. This randomized trial was conducted to compare the efficacy of benzydamine (standard) and a new combination (sumac and rose water) in preventing radiation-induced OM.

METHODS

This was a phase II, triple-blind, active-controlled, randomized trial. The primary endpoint was OM, and the secondary endpoints were oral pain and QoL. Besides, the possible variables defining the outcomes were analyzed using the chi-squared test (univariate analysis) and binomial regression model (multivariate analysis).

RESULTS

Sumac-rose group had fewer high-grade OM (33% vs. 63%, odds ratio [OR] 0.28, 95% confidence interval [CI 95%] 0.08-0.93, P = 0.03) and better QoL (P < 0.05). Multivariate analysis confirmed these findings. Sumac-rose rinsing could also postpone the start of oral pain (hazard ratio [HR] 0.02, CI 95% 0.001-0.32, P = 0.001) and high-grade OM (HR 0.28, P = 0.03) compared with benzydamine.

CONCLUSIONS

The sumac-rose group had a lower OM rate and grade and higher QoL than the benzydamine group. In addition, the experimental group developed high-grade OM and oral pain later during the radiotherapy course. Further studies need to be conducted to assess the role of sumac and rose water in reducing grade 3-4 mucositis in patients who undergo chemoradiation for head and neck cancer.

Mitochondrial metabolism: a predictive biomarker of radiotherapy efficacy and toxicity

INTRODUCTION

Radiotherapy is a mainstay of cancer treatment. Clinical studies revealed a heterogenous response to radiotherapy, from a complete response to even disease progression. To that end, finding the relative prognostic factors of disease outcomes and predictive factors of treatment efficacy and toxicity is essential. It has been demonstrated that radiation response depends on DNA damage response, cell cycle phase, oxygen concentration, and growth rate. Emerging evidence suggests that altered mitochondrial metabolism is associated with radioresistance.

METHODS

This article provides a comprehensive evaluation of the role of mitochondria in radiotherapy efficacy and toxicity. In addition, it demonstrates how mitochondria might be involved in the famous 6Rs of radiobiology.

RESULTS

In terms of this idea, decreasing the mitochondrial metabolism of cancer cells may increase radiation response, and enhancing the mitochondrial metabolism of normal cells may reduce radiation toxicity. Enhancing the normal cells (including immune cells) mitochondrial metabolism can potentially improve the tumor response by enhancing immune reactivation. Future studies are invited to examine the impacts of mitochondrial metabolism on radiation efficacy and toxicity. Improving radiotherapy response with diminishing cancer cells' mitochondrial metabolism, and reducing radiotherapy toxicity with enhancing normal cells' mitochondrial metabolism.

The present and the future of benzydamine: expert opinion paper

Objectives

Benzydamine is a compound indicated in the treatment of symptoms of irritation/inflammation of the oropharyngeal cavity, including those associated with pain. Objectives of this expert opinion narrative review is to summarize current indicated benzydamine applications and elicit further ones to be explored.

Materials and methods

In this expert opinion paper, evidences underlying the mechanism of action and clinical application of benzydamine are reviewed. Insights are also provided on possible new clinical applications of the drug and new formulations.

Results

Current recognized indications of benzydamine include: relief of symptoms associated with inflammatory conditions of the mouth and oropharynx, symptomatic treatment of gingivitis and stomatitis, oral mucositis induced by chemotherapy and/or radiotherapy and post operative sore throat. In addition, among new applications that need to be explored experts embed: oral lichen planus, burning mouth syndrome, post intubation sore throat, antifungal action and new anticancer target agents induced mucositis.

Conclusions

Benzydamine is a very versatile compound able to play an auxiliary and adjuvant role in the prevention and treatment of oral cavity/oropharynx disorders. According to experts' opinion there is the need to design clinical trials to highlight novel possible applications of benzydamine and implemented translational analyses to fine-tune patients' selection and open future research scenarios.

Comparative evaluation of rapidity of action of benzydamine hydrochloride 0.3% oromucosal spray and benzydamine hydrochloride 3 mg lozenges in patients with acute sore throat: A phase IV randomized trial

BACKGROUND

Acute sore throat (ST) can occur as part of a common cold of viral origin or caused by pharyngeal bacterial pathogens. The majority of patients with acute ST complain of pain on swallowing and dry scratchiness which can have a negative impact on the quality of life (QoL). This study aimed to evaluate the time to pain relief in patients with acute ST, following a single administration of benzydamine hydrochloride (HCl) 0.3% oromucosal spray or benzydamine HCl 3 mg lozenges.

METHODS

This multicenter, randomized, active-controlled, open label, parallel-group, international phase IV study was conducted at 12 investigational centers in Poland, Hungary, and Russian Federation. The study population consisted of 363 adult patients with recent onset (≤3 days) of ST and a diagnosis of tonsillopharyngitis. The primary endpoint was to assess the efficacy of benzydamine HCl in ST pain relief at 2 minutes after a single-dose administration. Secondary endpoints included, among others, the assessment of a first perceived ST relief at 1 minute after a single-dose administration of benzydamine HCl spray or lozenge.

RESULTS

Both the spray and lozenges are effective in providing a ST relief starting already at 2 minutes after a single administration, with an effect lasting up to up to 4 hours. Clinical efficacy after 7 days of treatment and a good safety profile were also demonstrated.

CONCLUSION

Anesthetic and analgesic properties of benzydamine spray and lozenges effectively addressed the patient priority of a rapid relief of symptoms of upper respiratory tract infections (URTI).

Radioprotective countermeasures for radiation injury (Review)

A series of physiological and pathological changes occur after radiotherapy and accidental exposure to ionizing radiation (IR). These changes cause serious damage to human tissues and can lead to death. Radioprotective countermeasures are radioprotective agents that prevent and reduce IR injury or have therapeutic effects. Based on a good understanding of radiobiology, a number of protective agents have achieved positive results in early clinical trials. The present review grouped known radioprotective agents according to biochemical categories and potential clinical use, and reviewed radiation countermeasures, i.e., radioprotectors, radiation mitigators and radiotherapeutic agents, with an emphasis on their current status and research progress. The aim of the present review is to facilitate the selection and application of suitable radioprotectors for clinicians and researchers, to prevent or reduce IR injury.

A prospective interventional study of recombinant human interleukin-11 mouthwash in chemotherapy-induced oral mucositis

BACKGROUND

This prospective interventional study aimed to evaluate and analyse the efficacy of rhIL-11 mouthwash compared to Kangfuxin fluid in treatment and blank control in prevention of oral mucositis (OM) in patients receiving chemotherapy.

MATERIALS AND METHODS

In total, 50 patients in the treatment group and 62 patients in the prevention group were included. Subsequently, each group was divided into an experimental group and a control group. In the treatment group, the experimental patients received recombinant human interleukin-11 (rhIL-11) mouthwash, whereas the control group received Kangfuxin fluid. In the prevention group, experimental patients still received rhIL-11 mouthwash based on routine oral care, whereas the control group only received routine oral care. Meanwhile, we observed and recorded the efficacy in the treatment group, and the occurrence and grades of OM in the prevention group.

RESULTS

Through statistical analysis, the results showed that on the seventh day of treatment, the experimental group showed more improvement compared to the control group, and it was statistically significant (p = 0.032). The average healing time in the experimental group (3.59 ± 1.927 days) was shorter than that in the control group (4.96 ± 2.421 days; p = 0.031). In the prevention group, we observed the incidence of oral mucositis. No significant differences were found in the occurrence and grades of OM in the experimental and control groups (p = 0.175).

CONCLUSION

Our preliminary results indicate that rhIL-11 mouthwash may be a superior option to treat OM, especially in severe cases, compared to Kangfuxin fluid. However, there is no advantage in prevention.

Anti-inflammatory mouthwashes for the prevention of oral mucositis in cancer therapy: an integrative review and meta-analysis

PURPOSE

Mucositis is severely painful and often reported as one of the most distressing adverse effects of cancer therapy; it is a significant threat to quality of life as well as life itself. Anti-inflammatory agents may modulate physiologic mechanisms that perpetuate mucositis and be useful in prevention efforts. Because systemic anti-inflammatory agents are not appropriate for many patients, locally acting agents (mouthwashes) may be more feasible for use. This review and meta-analysis evaluates the role that anti-inflammatory mouthwashes have in preventing or reducing oral mucositis associated with chemotherapy and radiation therapy.

METHODS

A systematic literature review was conducted to identify studies evaluating the efficacy of anti-inflammatory mouthwashes to prevent therapy-associated mucositis. Meta-analysis was conducted to determine efficacy in preventing any mucositis and dose-limiting mucositis.

RESULTS

Eight peer-reviewed publications were identified; corticosteroid and nonsteroidal anti-inflammatory mouthwashes are effective in reducing overall incidence of mucositis and are associated with lower severity of mucositis. Meta-analysis reveals significant reduction in symptomatic mucositis incidence (OR 6.00, 95% CI 4.39-8.20, p < 0.0001) and reduction of dose-limiting mucositis (OR 2.12, 95% CI 1.07-4.28, p = 0.032).

CONCLUSION

Mouthwashes containing anti-inflammatory agents are a potential effective means to prevent or reduce mucositis associated with cancer therapy. There are limited adverse effects from these agents, and adherence is high, indicating safety and feasibility of use. Anti-inflammatory mouthwashes should be considered for supportive care in persons at risk for mucositis and must be further evaluated to investigate efficacy across multiple chemotherapy agents, adverse effects, and impacts on symptoms, pain, and quality of life.

Casein Microgels as Benzydamine Hydrochloride Carriers for Prolonged Release

This research aims to investigate the properties of nano- and micro-sized casein hydrogels crosslinked by sodium tripolyphosphate as drug delivery systems. Benzydamine hydrochloride was chosen as a model hydrophilic drug. The gels were synthesized by varying different parameters: casein concentration, casein/crosslinking ratio, and addition of ethanol as a co-solvent. The electrostatic attractive interactions between the casein and the sodium tripolyphosphate were confirmed by FTIR spectroscopy. The particle sizes was determined by dynamic light scattering and varied in the range between several hundred nanometers and several microns. The yield of the gelation process was high for all investigated samples and varied between 55.3% and 78.3%. The encapsulation efficiency of the particles was strongly influenced by the casein concentration and casein/crosslinker ratio and its values were between 4.6% and 22.4%. The release study confirmed that casein particles are useful as benzydamine carriers and ensured prolonged release over 72 h.

Interaction between properties of commercial Australian honey and saliva: in vitro exploratory study of a potential mechanism in the treatment of oral mucositis

OBJECTIVES

Oral mucositis is a debilitating oncology treatment side effect, with honey identified as a viable management option due to established wound-healing abilities. However, effects of saliva on properties attributed to honey's wound-healing abilities is unknown. Therefore, this study aimed to identify interactions between saliva, and antioxidant characteristics and pH of honey.

METHODS

Saliva was collected from 15 healthy participants (Females n=9; mean age=34.1 ± 11.2 years). Centrifuged salivary supernatant, whole saliva, and water were independently used to dilute commercial Australian honeys (n=42). Antioxidant characteristics (DPPH and FRAP) and pH of diluted honeys were analysed, and differences between dilution conditions were determined.

RESULTS

Honey and saliva dilutions increased antioxidant characteristics compared to water, and addition of honey to saliva reduced pH compared with saliva alone. There were significant differences between dilutions for FRAP and pH, and water and salivary conditions for DPPH (p<0.001). No difference was observed between salivary conditions for DPPH (p=0.931), suggesting smaller cells remaining in the supernatant possess antioxidant abilities. However, differences observed for FRAP suggest precipitable molecules, including epithelial and food debris, could provide additional antioxidant power.

CONCLUSIONS

The addition of saliva to honey may support properties attributed to honey's wound-healing abilities and should be considered in the context of oral mucositis management.

Association of MTHFR and ABCB1 polymorphisms with MTX-induced mucositis in Chinese paediatric patients with acute lymphoblastic leukaemia, lymphoma or osteosarcoma-A retrospective cohort study

WHAT IS KNOWN AND OBJECTIVE

MTX pharmacology and toxicity involve several metabolizing enzymes and transporters whose functions have been suggested to be altered by genetic polymorphisms. The current study is to investigate the relationship between the genetic variation and MTX-induced adverse drug effects.

METHODS

A total of 80 paediatric patients (aged 1-14 years) were enrolled in this study. Toxicity was assessed according to the National Cancer Institute Common Terminology Criteria for Adverse Events version 4.0 scoring system. Genotyping was performed by MassARRAY Assay method. Data were analysed using Spss statistical package version 17.0 and Plink v1.07 software. The HWE was tested by a chi-square test. The Fisher's exact test (chi-squaretest) was used to compare the distributions of genotypes between cases and controls. OR and 95%CI were applied to evaluate the association of genetic variants with the presence of mucositis using unconditional logistic regression.

RESULTS AND DISCUSSION

Mucosal inflammatory injuries were found in 28 children. SNPs of rs1128503 (p = 0.0022, OR = 3.04, 95%CI = 1.39-6.64) and rs1045642 (p = 0.0052, OR = 2.38, 95%CI = 1.15-5.00) located in the gene of ABCB1 and SNPs of rs1801133 (p = 0.040, OR = 2.50, 95%CI = 1.06-5.88) located in the gene of MTHFR show marked impacts on the risk of developing mucositis.

WHAT IS NEW AND CONCLUSION

SNPs of ABCB1 rs1128503, rs1045642 and MTHFR rs1801133 can be risk predictor for MTX-induced mucositis in Chinese paediatric patients diagnosed with acute lymphoblastic leukaemia, lymphoma or osteosarcoma.